Basic Information
| Provider Information | |||||||||
| NPI: | 1659821585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RISGIMM, LLC | ||||||||
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| OtherOrganizationName: | PLANT CITY MRI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 W ALEXANDER ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335637100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2016 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | GOODEMOTE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8635770303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD., RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.